Malaria: an uncommon presentation in a traveler visiting friends and relatives

A 48-year old African male presented to our Emergency Department with intermittent fever (up to 38.5°C)and mental confusion. Since the previous week, he had persistent headache, cough and pollakiuria, with some episodes of urinary incontinence and nocturia. For this problem, he had just performed a urine exam and an urinoculture, which didn’t show any signs of infection. The patient’s sister reported that he had been living in Italy for 18 years and  recently completed a trip of about one month in Ghana, to meet his family. Since his  return to Italy, he appeared confused and often manifested inappropriate behavior. His medical history was unremarkable; he did not take any medication. He presented with elevated blood pressure 180/100 mmHg, heart rate of 100 bpm, respiratory rate of 20 breath/min, body temperature of 38.5°C.
He was awake and responsive, but confused. He was able to perform simple orders but with difficulty and appeared globally slowed in his movements. The neurological examination was, moreover, within the limits. He didn’t show meningeal sings, strength or sensitivity deficits. The physical examination of thorax and abdomen did not show any pathological sign. Laboratory exams showed: normochromic normocytic anemia (haemoglobin 9.9 g/dl), normal WBC and formula, slight increase in C reactive protein (PCR 22 mg/l) and procalcitonin (PCT 1.2 μg/l), hyponatremia and hypochloremia (Na 128 mmol/l, Cl 96 mmol/l), a mild increase of creatinine (1.22 mg/dl), INR (1.21), total bilirubin (1.6 mg/dl) and LDH (274 U/L), normal transaminases and glycemia. He performed a TC scan which proved no acute brain injury; it showed however a hypodense lesion in the frontal right lobe, suggesting previous ischemic damage. Abdominal ultrasound resulted non-pathologic, as well as chest x-rays. In order to rule out encephalitis he underwent lumbar puncture, which resulted normal. Cerebrospinal fluid PCR for common neurotropic viruses resulted negative. We collected blood cultures and urine cultures, which resulted negative too. An RDT-ICT for malaria was then performed, in view of the recent trip to Ghana, in an endemic area, the test resulted positive for Pf. The patient was admitted  to the local department of Tropical Diseases where he performed a QBC (Quantitative Buffy Coat) which confirmed positivity for Pf and a hemoscopy, which documented 201 Pf trophozoites on 200 wbc, corresponding to a parasitaemia of 0.2%. Therefore, he started therapy with oral dihydroartemisinin–piperaquine (4 mg/kg dihydroartemisinin and 18 mg/kg piperaquine, once daily for 3 days). Despite negative parasite research on stools and urines, serology for anti-schistosoma antibodies resulted positive, so he was treated for schistosomiasis with praziquantel (40 mg/Kg for 3 days). Initially after hospitalization, the patient appeared confused and disoriented; he made some self-injurious attempts, requiring a close monitoring period to prevent self harm. He performed then a brain MRI that showed multiple hyperintense foci, in T2 and FLAIR, within peri and supraventricular white matter and in the brain stem, consistent with a vasculo-jalinotic cerebropathy. The EEG was unremarkable. After therapy, there was a noticeable improvement in clinical and neurological conditions, together with the decline and negativization of parasitaemia. We mutually found a constant rise in blood pressure levels, often above 200/100 mmHg, consequently he carried out the tests to exclude secondary hypertension, which resulted non-conclusive. The echocardiogram showed signs of hypertensive cardiomyopathy with diastolic dysfunction, the fundus exam evidenced a II grade hypertensive retinopathy and signs of previous chorioretinitis, microalbuminuria emerged at the urine exam. In view of those indirect signs of organ damage, he started antihypertensive therapy reaching a good control of blood pressure levels at discharge.